Anesthesia for intracranial vascular procedures is complex because it requires a balance of several competing interests and potentially can result in significant morbidity and mortality. Frequently, periods of ischemia, where perfusion must be maintained, are combined with situations that are high risk for hemorrhage. This review discusses the basic surgical approach to several common pathologies (intracranial aneurysms, arteriovenous malformations, and moyamoya disease) along with the goals for anesthetic management and specific high-yield recommendations.